Evolving Plastic Surgery

Dr. Geraldine Lee is a consultant with the Plastic, Reconstructive, and Aesthetic Surgery Service at Tan Tock Seng Hospital (TTSH), Singapore. She also serves as the Associate Program Director for the Singapore Integrated Program for Plastic Surgery, a national residency program.

Through this article, Dr. Geraldine Lee highlights the significant advancements in reconstructive plastic surgery, emphasizing the transformative impact of super microsurgery, minimally invasive techniques, and 3D printing on patient care and surgical outcomes.

Advancing Training and Technology in Plastic Surgery

I am a consultant with the Plastic, Reconstructive, and Aesthetic Surgery Service at Tan Tock Seng Hospital (TTSH), as well as the Associate Program Director for the Singapore Integrated Program for Plastic Surgery, a national residency program. As one of the tertiary government hospitals in Singapore and a core rotation for our residents, I am constantly looking for ways to enhance their training experience. I am also a member of the 3D printing workgroup in TTSH and one of the early users of this technology in plastic surgery cases in our hospital.

Emerging Trends in Reconstructive Plastic Surgery

In reconstructive plastic surgery, several significant trends are shaping the field, particularly in surgical techniques and the incorporation of technological advancements into our practice.

The advent of super microsurgery has transformed the field of reconstructive surgery. It has afforded us greater freedom to plan our reconstructions, such as in the adoption of freestyle flaps that address not only soft-tissue coverage but also acceptable cosmesis at the donor site. Patients classically deemed ‘difficult-to-treat,’ such as those with advanced peripheral vascular disease previously deemed unsuitable for limb salvage, can now be considered for reconstruction. Super microsurgery has also revolutionized the management of lymphedema, a condition previously managed with non-surgical therapies and where surgery was used to treat the irreversible complications of the disease.  Recent advancements in imaging techniques have allowed surgeons to better evaluate lymphatic vessel anatomy, permitting more reliable pre-operative planning and improved surgical results.

In the field of cancer surgery, the increasing use of minimally invasive techniques for oncologic resections has spurred a corresponding adoption of plastic surgery due to the smaller incisions available for flap inset and microsurgical anastomosis. Minimally invasive surgery (MIS) offers notable benefits to patients: less postoperative pain, less scarring, shorter hospital stays, faster recovery times and an improved immune response.

Advancing Surgical Precision with In-House 3D Printing

Before having an in-house 3D printing service, which was set up in 2021, any customized intra-operative guides and models would take weeks to obtain. In addition to the difficulty in using this technology for time-sensitive cancer cases as well as facial trauma cases, it would also cost a lot more as these were obtained from overseas.

Following the availability of an in-house 3D printing lab, we are now able to obtain such a model in 3-5 working days. One such case was a patient who sustained an orbital floor fracture from a motor vehicle accident. We were able to print a model of the patient’s orbit from the Computer Tomographic scan performed, which allowed the patient to directly visualize their anatomy with the orbital floor defect before surgery and aided in pre-operative counseling. In an ideal situation, a patient-specific implant would be made, but the lead time required and prohibitive costs, especially in government service, required us to consider alternatives. The same orbital model used for counseling was then used to trim and contour an orbital plate to fit her anatomy. This model can be sterilized and used intra-operatively for further fine-tuning if required. In general, it enhances accuracy and reduces operative times.

Holistic Recovery and Quality of Life

A key tenet of reconstructive plastic surgery has always been not just the restoration of function but also the restoration of form and cosmesis for our patients. A large proportion of our reconstructive caseload comes from patients’ post-tumor extirpation surgery or complex and challenging wounds. While these are not the typical patients thought of as “belonging” to the realm of plastic surgery, it is not sufficient just to fill a defect or reconstitute function. Increasingly, ensuring a cosmetically acceptable outcome and, in some cases, an even more aesthetic visual result is paramount. The goal is a comprehensive multi-disciplinary approach to holistic recovery, physical, psychological, and emotional, with a focus on Quality of Life.

Take, for example, a middle-aged patient with breast cancer and breast ptosis due to aging. We no longer just perform breast reconstruction for the post-mastectomy side but offer symmetrization procedures to achieve overall harmony by improving the aesthetic outcome of the contralateral ptotic breast in the same setting.

A patient with a head and neck tumor involving the sacrifice of the facial nerve no longer needs to consign himself to permanent disfigurement. Facial reanimation procedures have allowed for the restoration of facial symmetry and the regain of spontaneous neurological function.

Enhancing the Patient Experience

Adopting emerging techniques and technologies in reconstructive plastic surgery offers transformative opportunities but also presents potential challenges. These techniques and technologies have altered the entire patient experience.

Starting from the initial consultation, education applications, as well as virtual reality and augmented reality imaging systems, enhance patient education and simulation of surgical outcomes.

Pre-operatively, the use of 3D printing solutions allows for patient-specific implants and customized jigs, enhancing accuracy and reducing operative times by allowing the surgeon to pre-contour implants before surgery or decide on the area of resection with jigs customized to a patient’s anatomy.

Super microsurgery and MIS techniques have pushed the boundaries and expanded the group of patients that can benefit from reconstructive procedures.

However, we need to be cognizant of the potential consequences of the use of these emerging approaches. For example, in the field of super microsurgery and MIS, there is a steep learning curve for surgeons, requiring extensive training and certification. Longer operating times are par for the course, especially in the initial phase, as well as increased costs because of acquiring and maintaining the equipment required.

In a government hospital, the benefits of such techniques must be weighed carefully against the extra expenditure imposed; these increased costs are not always compensated for by shorter hospital stays. Careful selection of patients is essential to maximize the benefits.